MEDICARE: GLENN RICHARD JOHNSTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME0018091	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME0018091	OTHER	FL	MEDICAL LICENSE

General Provider Information

NPI Number	:	1396808184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN RICHARD JOHNSTON M.D.

Provider Business Mailing Address
First Line	:	2304 ALOMA AVENEUE
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792
Country	:	US
Telephone Number	:	407-478-8840
Fax Number	:	407-478-8841

Provider Business Practice Location Address
First Line	:	2304 ALOMA AVE
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-3330
Country	:	US
Telephone Number	:	407-478-8840
Fax Number	:	407-478-8841

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	03/07/2023

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